Impact of Covid -19 incidence rate and government-initiated risk communication measures on individual’s NPI practices

Background Non-pharmaceutical interventions (NPI) are the most widely recognized public health measures recognized globally to prevent the spread of Covid-19. NPIs’ effectiveness may depend on the type, combination of applied interventions, and the level of proper public compliance with the NPIs. The expected outcome of behavioural practices varies relative to the intervention duration. Objectives This study aimed to assess the trend of community compliance to NPI with Covid-19 incidence and government-initiated interventions, and its variation by residence and sociodemographic characteristics of people. Methods A weekly non-participatory field survey on individuals’ NPI practices was observed from the 41st epidemiological week of October 5th, 2020, to the 26th epidemiological week of July 4th, 2021, a total of 39 weeks. The survey covered all 14 regional and national capital cities in Ethiopia. Data collection for the three NPI behaviours (i.e., respiratory hygiene, hand hygiene, and physical distance) was managed weekly at eight public service locations using the Open Data Kit (ODK) tool. The Covid– 19 incidence data and public health measures information from August 3rd, 2020 to July 4th, 2021 were obtained from the Ethiopian Public Health Institute (EPHI). Results More than 180,000 individuals were observed for their NPI practice, with an average of 5,000 observations in a week. About 43% of the observations were made in Addis Ababa, 56% were male and 75% were middle age group (18–50 years). The overall level of NPI compliance was high at the beginning of the observation then peaked around the 13th– 15th epidemiological weeks then declined during the rest of the weeks. The peak NPI compliance periods followed the high Covid-19 death incidence and government-initiated intensive public health measures weeks. Respiratory hygiene had the highest compliance above 41% whereas hand hygiene was the lowest (4%). There was a significant difference between residents of the capital city and regional cities in their level of compliance with NPI. Females comply more than males, and individuals had increased NPI compliance at the bank service and workplaces compared to those in the transport services at P = 0.000. Conclusion An increased level of compliance with NPI was observed following intensive government-initiated Covid-19 prevention measures and an increased Covid-19 death incidence. Therefore, the intensity of government-initiated risk communication and public advocacy programs should be strengthened, possibly for similar respiratory disease pandemics in the future.

Yes -all data are fully available without restriction  Individual behavioral practices are advised as vital to halt the development of COVID-19, although countries have employed a variety of context-based, diverse PHSM interventions [5].Few studies attempted to assess the efficacy of various NPI practices adopted by governments of various nations [2,3].Haug and colleagues [2] gathered thousands of implemented NPIs from 79 different countries and discovered that no one best NPI can stop the spread of Covid-19.Instead, the researchers found several combinations of interventions that can drastically reduce the transmission rate.Curfews, limitations, lockdowns, as well as limiting and restricting locations for public meetings, were shown to be the most effective NPIs in this study [2].In a comparable cross-country study, [3] assessed the efficacy of eight NPI interventions related to case identification, environmental measures, health care, and public health capacity, resource allocation, risk communication, social distancing, travel restriction, and returning to normal life.This study demonstrated that risk communication had the greatest impact on the population as a whole.The authors emphasized that risk communication strategies, such as providing general information about Covid-19 or using a face mask, were less likely to enforce any particular behavior on individuals but had a significant impact on the public.
The WHO created the "Covid-19 Global Risk Communication and Community Engagement Strategy" after considering risk communication to be a potent tool for altering people's behavior and willingness to adhere to public health measures [6].The ability to compare the impact of interventions was limited since many NPIs were introduced at the same time or at separate times [2,5,7].Sharma and colleagues mathematical model [4,7] highlighted the importance of local context and suggested a dozen assumptions be taken into account for a reliable estimation of the effect of NPIs [4,7].However, several studies concurred and suggested that combined NPIs were the most efficient way to limit the spread of Covid-19 [2][3][4][5]8].
The first Covid-19 case was found in Ethiopia in the second week of March 2020, and as of the most recent report (October 18, 2022), there were about 500,000 instances of infection [9].Since the introduction of the infection, the federal government has put several NPI measures into effect across the nation, including the implementation of the provisions of a State of Emergency, such as the closing of the international land border, the cancellation, closure, and restriction of public gatherings, school uniforms, public awareness campaigns, personal protective measures, case detection, isolation, and quarantine, among other things.Regional governments had also placed the various implementation strategies within the context of local and regional capabilities [1,10].The Federal Ministry of Health's (FMoH) Ethiopian Public Health Institute (EPHI) takes the lead in coordination with regional partners and governments [10,11].
The three NPI measures-mask use, physical separation, and hand hygiene-were the Covid-19 interventions that were used the most frequently on an individual basis.In the second week of June 2020, [12] investigated these personal safety precautions among Addis Ababa city government employees.They found that more than 90% of participants used face masks, washed their hands, and maintained physical distancing [12].A population of 12,056 residents of Addis Ababa city participated in a weekly NPI monitoring cross-sectional non-participatory observation from April to June 2020 for 10 uninterrupted weeks.The study found an increase in proper hand hygiene from the baseline of 24% to 33%, proper physical distance from 34% to 43%, and mask use from 24% to 77% in week 10 [11].This study showed the peak of practicing proper respiratory hygiene took 6 weeks after the baseline within the context of practicing the measures of State Emergency [13].Another study in the country, Bule Hora Town West Guji Zone, during the last weeks of September 2020 found that 38% of the participants had good social distancing practices [14].
We developed a research question associated with the level, and trend of NPIs after the lifting of the actions of the State of Emergency: what are the level and likely trends in the vacuum of public-supported NPI intervention?The current study focuses on determining the level, and the trend of the weekly changes in the three individual-level NPI behaviors.This is an urban population and time-expanded extension of the weekly NPI monitoring non-participatory observational research [11].

Study design, study area, setting, and period
This cross-sectional study design tracked people's weekly NPI behaviors in several public places throughout the urban centers of Ethiopia.The NPI techniques of people monitoring were first implemented in Addis Ababa in April 2020, and they have since spread throughout the entire nation, encompassing all regional capital cities.Before 2020, there were nine regional states, but the Federal Government of Ethiopia now has 11 regional states and 2 chartered cities.Two new areas, Sidama and South West Ethiopia Regions, were just established in June 2020.Weekly monitoring data from 15 cities, including Addis Abeba, Bahir Dar, Gondar, Adama, Hawasa, Asosa, Gambella, Diredewa, Harar, Hosana, Jigjiga, Jimma, Semera, Mekele, and Welayta Sodo, were obtained for the current study.Ethiopia's overall population is expected to be 105,166 000 in 2022, according to CSA projections [15].
The data collection period spanned 39 weeks, from October 4, 2020, to July 4, 2021, with a 2-week interruption in the middle (27 th and 28 th weeks).
The three NPI behaviors (mask use, hand hygiene, and physical distance) were observed weekly at eight public service locations, including places of worship, medical institutions, markets, banks, public transportation hubs, restaurants, and workplaces.These sites assumed an increase in COVID-19 transmission when individuals were taking public services, such as marketing, accessing transport services, and attending churches.

Source population
About 23,880, 000 Ethiopian urban inhabitants served as the study's source population [15].Around 7,333,908 people resided in the study's sample towns in total.The location of each town is indicated in Figure 1.

Monitoring protocol, Data collection tools, and Data collection procedure
This study is an extension of the Covid-19 monitoring in Ethiopia, hence monitoring protocol, data collection tools, and data collection procedure was similar to the description mentioned in the previously published report [11].

Data management and analysis
For data management and analysis, the ODK server's raw data were obtained in excel format and exported to SPSS V 26 for data cleaning and analysis.All regional town observation data were combined to compare with Addis Ababa because that city's population made up 51% of the study's total population.Tables, figures, and descriptive statistics were used to present the data.Line and bar graphs were used to display the weekly trend, variations by service facilities, sex, and age group, and appropriate mask use, appropriate hand hygiene, and appropriate physical distancing practices.Using the Chi-square test, the level of NPI practices in Addis Ababa and nearby regional cities was examined.

Ethical considerations
This study had been granted ethical approval from the Institutional Review Board (IRB) of the College of Health Sciences at Addis Ababa University.The detailed procedure was presented in the previous publication [11].Data collection was anonymous and the observers acted similarly to study subjects in observation sites when collecting data.

Study participants
More than 180,000 people were weekly observed for their NPI practice for a period of 39 weeks, although the observation was halted for two weeks.On average 5,000 weekly observations have been made from Addis Ababa and major regional cities.The proportion of observation from the capital city, Addis Ababa was 43% and from major regional cities 57%.Males' participation in the observation had a slightly higher proportion, 56%, compared to females, 44%.The middle age group, 18-50 years were the biggest proportion accounts for 75% followed by the highest age group greater than 50 years accounts 14% (Table 1) Overall trends of Proper NPI practice

Proper respiratory hygiene
From the three NPIs, the community had better compliance to respiratory hygiene followed by physical distance than hand hygiene.The respiratory hygiene compliance at a national level was 41% at the start of the observation week and declined to the lowest proportion of 32% holding for several weeks, then showed weekly progress up to 48% and maintained through the 26 th to the 30 th weeks Again, the proportion of proper respiratory hygiene compliance showed a continuous decline to 39% until the last observation week (Figure 2).However, there was a big difference in respiratory hygiene compliance between Addis Ababa city and major regional cities; there was higher compliance in Addis Ababa city across the observation period than in the regional cities and this difference is statistically significant at P<0.001.Increased compliance was also observed in both Addis Ababa and regional cities around the 26 th through the 30 th weeks (Figure 3)

Proper physical distancing
Proper physical distancing was the second NPI practice the community complied with next to respiratory hygiene.The proportion of proper physical distancing at a national level range from 14% -22% in the observation weeks.Similar to respiratory hygiene, the declined weekly trend from the start showed a small increment around the 29 th through the 31 st weeks (Figure 2).The proportion of proper physical distancing across the observation period in Addis Ababa ranged from 21% to 31% whereas the proportion in major regional cities was 8% -18 %.There is a big difference in proper physical distance practice between Addis Ababa city and regional cities, this difference is again statistically significant at P<0.001.(Figure 3).

Proper hand Hygiene
Proper hand hygiene was the least NPI practice the community complied.The proportion at national level ranges from 4% -10% during the observation weeks (Figure 2).The overall proportion of proper hand hygiene practice showed a declining trend in both Addis Ababa city and major regional cities.However, there was still a big difference in the proportion of proper hand hygiene between the two population groups, ranges from 7% -16% and 2% -7%, respectively.This difference is also statistically significant at P<0.001 (Figure 3).

Figure 2 Here
Figure 3 Here

Proper respiratory hygiene
An overall analysis combining the 39 weeks observation data showed that the proportion of proper respiratory hygiene compliance at the different service facilities at national level ranges from 25% -54%; the highest compliance was observed at the bank and the least at food and drink establishments.The stratified analysis of proper respiratory hygiene by cities for the different facilities ranged from 40% -80% and 14% -35% in Addis Ababa and regional cities, respectively.Highest public compliance was observed in Addis Ababa at all the service facilities compared to the regional cities (P<0.001)(Figure 4).

Proper physical distancing
The proper physical distancing public compliance at the different service facilities at the national level ranges from 9% -23%.Similar to the respiratory hygiene the highest compliance was recorded at the bank but the least at the transport service.The stratified analysis of proper physical distancing by observation places for the different facilities ranges from 13% -35% and 7% -16% in Addis Ababa and regional cities, respectively.The highest and the least proportion of compliance in Addis Ababa was at the bank and transport service facilities, respectively.Although the least proportion of compliance in regional cities was at the transport service but the highest compliance was at the workplace.An overall highest public compliance was observed in Addis Ababa at all the service facilities compared to the regional cities.This difference is statistically significant at P<0.001 (Figure 5).

Proper hand hygiene
The proper hand hygiene public compliance at the different service facilities at the national level ranges from 0.2% -16%.The highest compliance was recorded at the food and drink establishments but the least at the transport service.The stratified analysis of proper hand hygiene by cities for the different facilities ranges from 0.3% -20% and 0.1% -12% in Addis Ababa and regional cities, respectively.Similar to the national level, the highest and the least proportion of compliance was recorded at the same facilities in both cities.An overall highest public compliance was observed in Addis Ababa city at all the service facilities compared to the regional cities, this difference is statistically significant at P<0.001 (Figure 6).

Variation of proper NPI practice by sex and age
A stratified analysis was performed to observe NPI practice difference by sex and age group within the observation city.The practice of the three NPIs in Addis Ababa was more than that in the regional cities, with statistical differences (p<0.001).Females tend to have increased respiratory hygiene practice relative to males, while the age group greater than 50 had better physical distancing than other age groups (Table 2).studies, organized efforts initiated by governments, public awareness advocacy and risk communication programs affect NPI adherence in a community [19][20][21].A population based bi-weekly survey (April to November 2020) from the US showed a substantial decrease of NPI adherence index from 70 at the beginning of the survey, maintain plateau at 50s during June and a slight increase to 60 in November [21].
The current author also reported a similar pattern of change in NPI compliance level in the community [11].Another community-based study that examine covid-19 community mitigation practices in Nigeria found that wide ranges of government measures, healthcare policy related to the pandemic and public campaign intervention programs affected individual behavior towards NPIs practices [20].
Throughout the observation period, proper respiratory hygiene compliance is consistently the highest from the three NPI practices in our study.At the beginning of the pandemic social distancing and handwashing were well accepted NPIs by many people worldwide as the most effective strategy to control the transmission compared to the face mask [22].Even before changing the current guideline WHO also declared as there was no evidence about face mask in protecting healthy individuals from Covid-19 infection [23].However, the embarking message by CDC about the benefit of face covering for the prevention of transmission against WHO influence people practice towards face mask use [24].Lately, the prevention of Covid-19 transmission through proper respiratory hygiene (wearing mask) is widely advocated throughout the world.On top of the regulatory public measures, several scientific evidences from the health sciences, advices from recognized public health institutions promote face covering as an efficient prevention method specially in resource limited settings [24][25][26][27].Public availability of this information and the increased rate of Covid 19 transmission might influence evidence based informed decision-making power of individuals to comply to face mask than the other NPIs.The feasibility of enforcing the mandatory use of face-mask at individual level while in service facilities and public places might also a reason for the higher proper respiratory hygiene compliance than other NPIs in the current study [4].
The level of compliance to each NPI is affected by several factors.The current study highlighted the variation of NPI compliance of individuals by place of residence, socio-demographic characteristics and at service provision facilities.People living in the capital city had a better compliance to the overall NPIs compared to regional cities residents.Except on physical distancing females were better compliance to the other NPIs than males and people at the bank and workplaces have better NPI compliance than at the transport service provision.Abdelhafiz and colleagues identified urban resident Egyptians had better knowledge and NPI practice compared to the rural residents [28].Females were more likely to follow good preventive practices, comply with wearing mask and hand hygiene than men in different populationbased studies in Africa [11,20,29].A previous weekly monitoring of NPIs at different service facilities have also a similar result [11].The availability of information, restriction and required procedures at institutions might be the main reason people to comply with NPI measures.
Although monitoring weekly NPI practice data from the community is an important source of information for decision, but this study has also several limitations which was mentioned in previous publication [11].

Conclusions and recommendations
Generally, community compliance to NPI practice showed a decline trend in Ethiopia but an increased compliance was also observed following the implementation of government initiated public measures.
Comply to proper respiratory hygiene is by far higher than hand hygiene and physical distancing.Besides, the overall NPI practice level is varied by place of resident, sociodemographic characteristics of individuals and service provision facilities.Therefore, public initiated risk communication and advocacy measures should be strengthened to increase community compliance to NPI practices. 1

Percentage Observation weeks
Hand hygiene, Addis Ababa Hand hygiene, Regional cities Physical distance, Addis Ababa Physical distance, Regional cities Respiratory hygiene, Addis Ababa Respiratory hygiene, Regional cities disclosure statement that describes the sources of funding for the work included in this submission.Review the submission guidelines for detailed requirements.View published research articles from PLOS ONE for specific examples.This statement is required for submission and will appear in the published article if the submission is accepted.Please make sure it is accurate.Unfunded studies Enter: The author(s) received no specific funding for this work.Funded studies Enter a statement with the following details: Initials of the authors who received each award • Grant numbers awarded to each author • The full name of each funder • URL of each funder website • Did the sponsors or funders play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript?• NO -Include this sentence at the end of your statement: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.• YES -Specify the role(s) played.• * typeset The author(s) received no specific funding for this work.Competing Interests Use the instructions below to enter a competing interest statement for this submission.On behalf of all authors, disclose any competing interests that could be perceived to bias this work-acknowledging all financial support and any other relevant financial or nonfinancial competing interests.This statement is required for submission The authors have declared that no competing interests exist.Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation and will appear in the published article if the submission is accepted.Please make sure it is accurate and that any funding sources listed in your Funding Information later in the submission form are also declared in your Financial Disclosure statement.View published research articles from PLOS ONE for specific examples.NO authors have competing interests Enter: The authors have declared that no competing interests exist.Authors with competing interests Enter competing interest details beginning with this statement: I have read the journal's policy and the authors of this manuscript have the following competing interests: [insert competing interests here] /A" if the submission does not require an ethics statement.General guidance is provided below.Consult the submission guidelines for detailed instructions.Make sure that all information entered here is included in the Methods section of the manuscript.N/A Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Format for specific study types Human Subject Research (involving human participants and/or tissue) Give the name of the institutional review board or ethics committee that approved the study • Include the approval number and/or a statement indicating approval of this research • Indicate the form of consent obtained (written/oral) or the reason that consent was not obtained (e.g. the data were analyzed anonymously) • Animal Research (involving vertebrate animals, embryos or tissues) Provide the name of the Institutional Animal Care and Use Committee (IACUC) or other relevant ethics board that reviewed the study protocol, and indicate whether they approved this research or granted a formal waiver of ethical approval • Include an approval number if one was obtained • If the study involved non-human primates, add additional details about animal welfare and steps taken to ameliorate suffering • If anesthesia, euthanasia, or any kind of animal sacrifice is part of the study, include briefly which substances and/or methods were applied • Field Research Include the following details if this study involves the collection of plant, animal, or other materials from a natural setting: Field permit number • Name of the institution or relevant body that granted permission • Data Availability Authors are required to make all data underlying the findings described fully available, without restriction, and from the time of publication.PLOS allows rare exceptions to address legal and ethical concerns.See the PLOS Data Policy and FAQ for detailed information.

Introduction
Individual level Non-Pharmaceutical Intervention (NPI) is part of the bigger public health and social measures (PHSM) of the World Health Organization (WHO) to prevent the spread of Covid-19 transmission.These behaviors include putting on a mask, having physical distancing, and using proper hand hygiene [1].In the early stages of Covid-19, governments from all over the world started a variety of PHSMs that can be implemented by individuals, institutions, communities, and local and national government bodies due to the lack of clear and proven medical treatments for Covid-19 and the paucity of global level available scientific evidence [1-4].Countries and governments were under pressure as disease incidence rose.

Figure 1
Figure 1 Here

Figure 2 .
Figure 2. Overall city-wide trends of proper NPI practices for 39 weeks, Oct 5/2020-July 4/2021 Note: Data were not collected on week 27 and 28

Figure 3 . 2021 Figure 4 .
Figure 3. Trends of proper NPI practice in the Addis Ababa vs regional cities, Oct 5/2020-July 4/2021 Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationPowered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation